Exam 1 Flashcards
ACE (in terms of pain)
Assess: for pain and rating
Care: manage patient
Educate: addiction, don’t wait until pain is severe
When do you see side effects of a med
Peak
IASP definition of pain
An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
McCaffery’s definition of pain
Whatever the pt says it is, whenever the pt says it is
JHACO standards (2)
All pts must be assessed for pain
All pts have the right to appropriate assessment and management of pain
Peak respiratory depression (IV, IM, SQ, epidural, transdermal)
IV: 15 min
IM: 30
SQ: 90
epidural: 6-12 hrs
transdermal: 12-18 hrs
Joint commission accredits pain specific components such as (4)
location
onset
alleviating factors
aggravating factors
Adaptation response
pt has pain but doesn’t show parasympathetic symptoms; withdrawal from social interactions & depression seen
Nociceptive pain and 4 steps
Normal
transduction (pain converted to electrical impulse in horns)
transmission (neurotransmitters regulate pain perception and go to cortex)
perception (we understand the pain)
modulation (modulate the pain)
endorphins
body’s natural morphine system, delays transmission of pain (also from placebo)
neuropathic pain
nerve injury usually peripheral
ex. diabetic neuropathy or phantom pain
Pain STIMULATING chemicals (5) and what do they do
histamine
bradykinin
acetylcholine
potassium
prostaglandins
they stimulate the inflammatory process
Pain CONTROLLING chemicals (3) and what they do
enkephalins
endorphins
serotonin
They modulate the pain
Biologic pain
Internal
Chemical pain
Caused by internal chemical, such as ulcers
Physical pain
caused by outside stimuli, like a tight cast
chronic intermittent pain
comes and goes like migraines
cancer related pain
from disease progression and treatment options
superficial pain
cutaneous, like a cut
Deep somatic pain
bone, muscle, blood vessels, connective tissue
visceral pain
pain from internal organs
localized pain
confined to site of origin
referred pain
pain that is felt somewhere else (like arm pain from an MI)
Intractable pain
high resistance to pain relief (nothing works)
Breakthrough pain
pain that occurs between doses of pain meds
acute pain
Mild-severe
sympathetic NS responses (observable)
related to a specific injury
resolves with healing
restless and anxious
reports of pain
pain behavior
definite start, occurs as a result of an injury, definite end time
Chronic pain
mild-severe
adaptation response
parasympathetic NS responses
cancer related pain
progression of cancer
treatment
acute or chronic
need large dose of pain med
Adaptation response
vital signs
facial expression
shifting away or guarding
reporting pain only if asked
sleepiness
limited physical activity
withdrawing
pain in the elderly
typically passive, may deny pain (ego or “normal” feeling)
more sensitive to drugs
chronic pain undertreated
sleep deprivation and fatigue=longer healing time
addiction
compulsion characterized by behaviors that include impaired control over drug use, compulsive use, continued use, despite harm and craving mostly for psychic effects
dependence
opioids taken over a long period of time with abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
not an addiction
state of adaptation
physical dependence
drug class specific withdrawal syndrome
physical withdrawal, suddenly stopped
Psychological dependence
emotional craving for drug effect
prevent occurrence with withdrawal symptoms
tolerance
decreased sensitivity to analgesic
properties of opioid with need for increasing doses to maintain level of pain relief
adequate pain relief no longer obtained
state of adaptation
pain assessment
triggers/relief
associated s/s
intensity (scale)
threshold (when they feel pain)
tolerance (max amount of pain someone is willing to take)
location
quality
onset and duration
personal meaning
allergies
OPQRST
objective signs
provoked by what
quality
region
severity
timing
objective pain signs (5)
sympathetic, parasympathetic, verbal, nonverbal, adaptation response
unreliable on their own
what do we want to do when managing pain (6)
reduce anxiety
prevention (periodic meds)
PCA
placebos
anesthetic blocks
non-pharmacological
what do placebos set off
the internal morphine system
adjuvant analgesics (4)
Given with or in place of other pain relief meds:
steroids
antihistamines
anticonvulsants
antianxiety
non-opioid analgesics
salicylates (aspirin)
acetaminophen (tylenol)
NSAIDS
aspirin side effects (2)
tinnitus
decreased effectiveness of NSAIDS
NSAIDs side effects (2)
increased sodium retention
GI bleeding and irritation
take with food or milk
adverse effects of opioids
resp depression
tolerance of side effects:
itching (solved with benadryl)
constipation (ambulate)
what does massaging do
releases internal morphine (endorphins)
contralateral stimulation
massage opposite of where injury is
diathermy
pulsations (like a sonogram), produces heat
what is TENS used for
intractable or chronic pain
nursing problems: pain
fatigue, impaired mobility, self care deficit, ineffective airway clearance, impaired gas exchange, hopelessness, ineffective coping, ineffective health maintenance, disturbed sleep pattern, deficit knowledge
Functions of body fluids (4)
transport nutrients to cells and waste away
maintain homeostasis
tissue lubricant
temperature regulation
ICF amount
2/3 of our body water
40% of our weight
ECF amount
1/3 of our body water
20% of our weight
intracellular spacing
1st spacing
when fluids are where they’re supposed to be
extracellular spacing
2nd spacing
fluid leak-edema
transcellular spacing
3rd space
synovial, CFS, pericardial, pleural [effusion- ascites], intraocular (areas with little to no water usually)
fluid is trapped
must be removed with a needle
leads to hypervolemia/weight gain
dehydration vs hypovolemia
dehydration: only ECF, electrolytes become more concentrated
hypovolemia: ICF and ECF fluid volume deficit, loss of electrolyte (ex. hemorrhage)
hypovolemia manifestations (8)
oliguria, tachycardia/pnea, generalized edema (non pitting), weight gain, fever, constipation, abdominal cramps
solvent
the liquid doing the dissolving
solute
the stuff getting dissolved
hydrostatic pressure
pushes fluid out of capillaries (interstitial space) and into interstitial fluid
plasma colloid osmotic pressure
holds fluid inside the capillary
pulling force of albumin
albumin holds fluid in capillaries, important w edemas
kidney failure=disruption
what happens when kidneys can’t filter out protein
kidney increase in colloidal osmotic pressure
how do age and body fat content affect fluid and electrolye balance
Age: body fluids increase in younger than older
Body fat content: thin and women> obese and men bc fat cells/adipose tissue have little water
GI factors effecting fluid/electrolyte balance
nasogastric suctioning, vomit, diarrhea
environmental factors effecting fluid/electrolyte balance
vigorous exercise, high altitudes, dry climates, alcohol, caffeine, diuretics, heart and blood vessels, respiration (insensible water loss)
hypovolemic shock
bad
temp regulation (up to 105F)
impaired thought process
sodium loss (abdominal cramps)
Behavior, skin, tongue, vitals, etc in fluid volume deficit
behavior: confusion, combativeness, coma
flattened veins, oliguria, dark, high specific gravity
skin: poor turgor, loss of IS space fluid
tongue: dry and furrowed
vital signs (low BP, high HR, high temp), SOB, paresthesia, muscle cramps
neuromuscular irritability
fatigue
nursing management of FVD
identify and assess, look to replace I&O, daily weight, abdominal girth measuring
FVD related factors
decreased fluid intake (imposed fluid restriction, inability to swallow or obtain fluids)
depression
increased needs for fluids (strenuous exercise, extreme heat or dryness, fever)
abnormal fluid loss (V/D, abdominal surgery, abnormal drainage, skin trauma, laxatives, enemas, blood loss, diaphoresis, polyuria)
FVD defining characteristics
extreme thirst
irritability
dizziness
weakness
fever
dry skin
dry mucous membranes
sunken eyes
poor skin turgor
decreased urine output
FVD interventions
encourage gradual fluids
lactated ringers
good skin care (moisturizing)
sodium/water retention
renal failure/nephrotic syndrome
decreased CO
liver disease/cirrhosis
hormonal problems (cushing’s=too much cortisol)
weight gain
swollen (enema), JVD, pulmonary edema, pleural effusion, altered LOC, seizures (cerebral edema)
excessive sodium or fluid intake causes (5)
IV infusion with Na, blood or plasma replacement
albumin infusion
administration of hypertonic solutions
GI irrigation with hypotonic solution
corticosteroid therapy
fluid volume excess (hypervolemia)
hemodilution
polyuria, decreased BUN, hematocrit, and specific gravity
strict I&O
monitor resp status and pulmonary complications, ABG, O2 therapy, sodium/fluid restrictions (meds w meals)
pt teaching: seasonings, NOT salt, hold water in mouth to moisten, 45 angle bed
what 2 kinds of meds cause hyponatremia
anticonvulsants and sedatives
hypernatremia causes (MODEL)
Medications (antacids), meals
osmotic diuretics
diabetes insipidus
excessive water loss
low water intake
euvolemic hypernatremia
sodium content increases while total body water remains near normal. usually caused by excess sodium intake
hyponatremia nursing interventions
monitor for confusion
remove underlying problem
hypernatremia defining characteristics (FRIED SALT)
Flushed skin
restless
increased BP and fluid retention
edema peripheral and pitting
decreased urine output and dry mouth
skin flushed
agitation
low grade fever
thirst
potassium normal values
3.5-5
hypokalemia
98% of body’s K+ is in the cell (excitability, conduction, contraction)
80% K+ exerted from kidneys
body can’t hold onto potassium
disturbances causing hypokalemia
suctioning, severe diaphoresis, chronic kidney failure, diuretic drugs (furosemide), excess insulin administration, asthma drugs, excessive sweating, vomiting
hypokalemia defining characteristics (DA SIC WALT!!)
decreased intestinal motility (N/V, ileus)
alkalosis (increased K+ secretion)
shallow respirations (causes alkalosis)
irritability
confusion, drowsiness
weakness, fatigue
arrythmias: tachycardia and irregular rhythm
lethargy
thready pulse
hyperkalemia related factors
intracellular shift (K+ release due to cell lysis)
impaired renal excretion
addison’s disease
renal insufficiency
drugs (diuretics)
rare if kidneys are functioning properly
hyperkalemia defining characteristics
muscle twitches, cramps, paresthesia
irritability and anxiety
low BP
dysrhythmias (bradycardia)
abdominal cramping
diarrhea
hyperkalemia interventions
no potassium-saving diuretics (loop instead)
kayexalate: contrasts hyperkalemia
effects: sits in intestines for 4-6 hrs
insulin
calcium glutamate
pt teaching: no salt subs and eat fruits and berries
normal Ca values
8.5-10.5
hypocalcemia causes (10)
hyperthyroidism
renal failure
pancreatitis
parathyroid impairment
excessive laxative use
lack of movement= decreased absorption
alcohol & nicotine
breastfeeding
anorexia/bulimia
burns or infection
hypocalcemia defining characteristics
nerve fiber irritability
anxiety
irritability
paresthesia around the mouth
diarrhea
skin conditions
muscle cramps/twitching/spasm
hyperactive DTRs
seizures
trousseau’s and chvostek’s signs
trosseau’s sign
hands and fingers spasm when blood flow is decreased
apply BP cuff to the pt’s upper arm, inflate to 20mmHg above SPB
if in 1-4 minutes, pt experiences: adducted thumb, flexed wrist and metacarpophalangeal joints, extended interphalangeal joints, carpopedal spasm
chvostek’s sign
tap pt’s face next to the ear
brief contraction of face
hypercalcemia related factors
hyperparathyroidism (increased Ca absorption)
breast cancer
renal failure
meds (vit d overuse, antacids, diuretics)
decrease in smooth muscle
dehydration
hypercalcemia s&S
nonspecific
confusion
muscle weakness
bone pain
kidney stones
arrythmias, cardiac arrest
excessive urination
hypercalcemia interventions
increase mobilization and hydration
avoid dairy
may need hemodialysis
Mg normal values
1.5-2.6
hypomagnesemia causes
poor dietary intake
intestinal malabsorption
excessive Mg excretion
drugs (laxatives, antibiotics, loop diuretics, thiazide diuretics)
hypercalcemia
hyperphosphatemia
metabolic acidosis
hypomagnesemia interventions
increase Mg supplements
educate about mg foods (broccoli, kale)
educate abt diuretic use
hypermagnesemia causes
renal failure
ingesting too much
tumor lysis syndrome
excessive drugs, antacids, mg sulfate
preeclampsia
DKA (makes you hold onto Mg)
hypermagnesemia defining characteristics
everything slows down!
bradycardia, hypotension
flushed skin
decreased muscle and nerve activity
hypoactive DTRs
generalized weakness
N/V
decreased bowel sounds, LOC
slow, shallow, depressed respirations
respiratory arrest
hypermagnesemia interventions
administer fluids
reorient pt
monitor respirations
monitor bowel movements
phosphate normal levels
2.5-4.5 in adults
6-7 in kids
hypophosphatemia S&S (cardiac, renal, blood, brain, lungs, GI muscles)
cardiac: hypotension, tachy, failure and arrest
renal: AKI
blood: anemia, hemolysis, thrombocythemia
brain: confusion, coma, encephalopathy, seizures
lungs: resp failure, pulmonary edema
GI: anorexia, diarrhea, ileus
muscles: weakness, paresthesia, neuropathy, rhabdomyolysis, tetany
hypophosphatemia nursing interventions
mild: high phosphorus diet (eggs, nuts, whole grains, meat, fish, poultry, milk)
moderate: oral supplements
severe: IV potassium phosphate or sodium phosphate and seizure precautions
arterial pH
% of hydrogen ions in a solution
(% lost or gained)
volatile acids
excreted from the body as a gas
nonvolatile/fixed acids
excreted by the kidneys
blood chemical buffers
1st line of defense
instantly regulates hydrogen
hydrogen is held or released in the plasma (immediate)
resp system in acid/base balance
controls CO2 within minutes
2nd line of defense
kidneys in acid/base balance
excrete or retain bicarb as needed
3rd line of defense
hours-days
resp failure (acid/base)
kidneys excrete water, regenerating carbonic acid, lose hydrogen, and retain bicarb
PaCO2
kidney disease
impairs excretion of fixed acids, resp system increases ventilation to get rid of excess acid as carbon dioxide
metabolic acidosis
ABG normal values
pH: 7.35-45
PaCO2: 35-45
HCO3: 21-28
resp acidosis risk factors
hypoventilation (COPD)
resp depression (any condition where pt retains CO2)
barbiturate or sedative overdose
Guillain-barre syndrome or some other neuromuscular weakening disease
ribcage injuries
resp arrest
how long does resp acidosis take to resolve and pH in acute and chronic
acute: within 3 days, low pH
chronic: longer than 3 days, pH normal
acidosis symptoms
headache, sleepy, confused, LOC, coma, too much CO2, less O2
seizures, weakness
diarrhea
SOB, coughing
increased HR
hypercapnia
N/V
acidosis treatment
monitor for all symptoms
correct underlying condition
assist with ventilation
maintain patent airway
aspirin in terms of alkalosis
can stimulate respirations
metabolic acidosis risk factors
cardiac arrest
aspirin overdose
excess production of acids
DKA
lactic acidosis
starvation with lactic acidosis
inadequate loss of acids (urema, renal tubular acidosis)
excess loss of base (severe diarrhea)
metabolic acidosis nursing interventions
treat underlying causes (diarrhea, DKA)
monitor K+ levels
monitor neurological status
provide mechanical ventilation
dialysis as ordered
metabolic alkalosis risk factors
loss of acids (vomiting, excess GI suctioning, diuretic therapy)
base or buffer imbalance (K+ deficit, excess NaHCO3 intake [Alka-Seltzer])
disease states (cushing’s kidney)
multiple transfusion
overcorrection of acidosis
nursing responsibilities for oncology
understand how lives are affected
understand the patho
identify pts at risk
prevention
nursing care
identify support services
support pts and family
incidence of cancer (age, gender, race)
higher in older ppl and men
high mortality rate among African Amercians
most common cancers
colon and lung
what does it mean to be cured of cancer
cancer free for 5 years
leading cause of stomach cancer
H. Pylori
benign cell growth
does not usually require intervention
tight adherence
no migration
orderly growth
normal chromosomes
continuous appropriate cell growth
specific morphology
small nuclear-to-cytoplasmic ratio
specific, differentiated
malignant cell growth
indicates cancer
loose adherence
migration
no contact inhibition
rapid or continuous
abnormal chromosomes
patho of carcinogenesis
normal cells turning into cancer cells
stages of carcinogenesis
initiation
promotion
malignant conversion/progression
metastasis
steps of metastasis
malignant transformation
tumor vascularization
blood vessel penetration
arrest and invasion
malignant transformation
some normal cuboidal cells have undergone malignant transformation and have divided enough times to form a tumorous area within the cuboidal epithelium
tumor vascularization
cancer cells secrete tumor angiogenesis factor (TAF) stimulating the blood vessels to bud and form new channels that grow into the tumor
blood vessel penetration
Cancer cells have broken off from the main tumor. Enzymes on the surface of the tumor cells make holes in the blood vessels, allowing cancer cells to enter blood vessels and travel around the body.
arrest and invasion
Cancer cells clump up in blood vessel walls and invade new tissue areas. If the new tissue areas have the right conditions to support continued growth of cancer cells, new tumors (metastatic tumors) will form at this site.
4 ways cancer cells spread
routes (liver, lymph nodes, lung, bone, brain)
seeding
lymphatic
blood-borne metastasis
seeding
projection and invading of surrounding tissue
lymphatic spread
pass between lymphatic circulation
blood borne metastasis
vascular system to distant sites, organs, and internal cavities
cancer risk factors
viruses and bacteria
physical agents (the sun, cigarettes)
chemical agents (tobacco, asbestos)
genetics
hormones (estrogen)
diet (processed foods like ham, bacon, burgers, hot dogs, red meat, organ meat, dyes)
CAUTION in cancer
change in bowel or bladder
a lesion that doesn’t heal
unusual bleeding or discharge
thickening or lump in breast or elsewhere
indigestion or difficulty swallowing
obvious changes in wart or mole
nagging cough or persistent hoarseness
cancer care and control (prevention levels)
primary: healthy people
secondary: screening for those at risk
tertiary: after diagnosis
approaches: education, regulation, host modification
grading of tumors
degree of malignancy
type of tissue
differentiation
numeric value
staging of tumors
stage 0-4
TNM system
T-extent of primary tumor
N-node involvement
M-extent of metastasis
T in TNM
1: 1-3 cm
2: 3-5 cm
3: 5-7 cm
4: 7+ cm
N in TNM
0: no nodes involved
1: mobile nodes
2: fixed nodes
M in TNM
0: no metastasis
1: demonstrable metastasis
2: suspected metastasis
stage 0 cancer
carcinoma in situ
stage 1-3 cancer
disease is more extensive, such as larger tumor size or spread
stage 4 cancer
spread to distant tissues and organs
cancer treatment (5)
surgery
radiation
chemo
biotherapy
bone marrow transplant
cancer treatment goals
cure, control, palliation, rehab
4 types of cancer surgery
diagnostic (excision)
prophylactic
palliative
reconstructive
3 types of biopsies
excisional (removes whole tumor)
incisional (removed part of tumor)
needle (removes tissue to diagnose)
wide vs radical excision surgery
wide: removes involved area
radical: removes whole thing
radiation therapy
primary, adjuvant, palliative
external beam (teletherapy)
internal radiation (brachytherapy, sealed-source, unsealed source)
radiation safety standards
distance (6 ft), time (30 min/8 hrs), shielding (in x-ray area)
avoid handling if dislodged
sealed internal radiation
stays in place by itself and becomes inactive. May need an applicator to keep in place. low level radiation
unsealed internal radiation
administered IV or IO so it’s distributed
brachytherapy
use of radioactive materials in contact with or implanted into the tissues to be treated
dysgeusia and xerostomia
dysgeusia (altered state of sensation)
xerostomia (dry mouth)
myelosuppression: thrombocytopenia
assess for bleeding
apply pressure to sites of needle sticks
avoid invasive procedures if possible
myelosuppression: leukopenia
abnormally low WBC count
brush and floss after every meal not if bleeding
no petro jelly
no exposure to dirt
no flowers
rinse toothbrush w bleach, no mouthwash
bathe daily w antimicrobial soap
nothing fresh
chemo goals
cure, control (increase survival time), palliate (decrease chance of life-threatening complication), antineoplastics
antineoplastic
pertaining to the prevention of growth and spread of cancer cells
types of chemo
primary
adjuvant
neoadjuvant (before surgery)
chemo guidelines
oncology certified nurse
verification
PPE
body fluids and excreta (contaminated 48h after chemo)
routes of chemo administration
regional
oral
IV
regional chemo (intra-arterial, intracavitary, intraperitoneal, intrathecal)
topical
intra-arterial (straight to organs)
intracavitary (bladder)
intraperitoneal
intrathecal (CNS)
IV chemo
VAD
PICC
extravasation
hypersensitivity reaction
extravasation
escape of blood from vessel into the tissue
destroys the tissue, skin is gone
life threatening (line of defense is gone)
can become easily infected
biotherapy
alters immunologic relationship between pt and tumor
restoration, modification, stimulation, augmentation of body’s immune system
growth factor inhibitors
biologic response modifiers
monoclonal antibodies
complementary treatment approaches
alternative/integrative therapy
bone marrow transplant (allogenic, autologous, and syngeneic)
allogenic: donor other than the pt (GVHD)
autologous: pt
syngeneic: identical twin
treatment modalities
nonspecific agents
interferons (IFN)
interleukins
monoclonal antibodies
interferons (IFN)
when used, shorten periods of neutropenia
inhibit/stimulate immune system
fatigue, muscle aches
flu-like symptoms
interleukins
strengthens immune response
hypotension, ascites, pulmonary edema, fatigue, weight gain, rash
monoclonal antibodies
destroy cancer cells
spares normal cells
anticancer drugs
adverse reactions
bone marrow suppression
N/V
anorexia
GI disturbance
alopecia
avoid preg
integumentary effects of cancer
skin reactions
mucositis
stomatitis
alopecia
reproductive system effects of cancer
sterility
loss of libido
impotence
oncologic emergencies
infection, septic shock
hemorrhage
hypercalcemia
tumor lysis syndrome
SIADH
disseminated intravascular coagulation
spinal cord suppression
superior vena cava syndrome
6 things to check for w cancer
imbalanced nutrition
risk for infection
impaired skin integrity
impaired tissue integrity
chronic pain
fatigue
psychosocial aspects of cancer
hospice
support for pt and family
promoting positive self concept
promoting coping
Titrate up and down for who
DOWN for non-malignant pts and elderly
UP for everyone else
Side effects of opioids and how to treat
build up tolerance after 3-5 days
causes constipation
ambulate, drink water and fiber
end product of muscle metabolism
creatinine
how much to elevate legs in fluid overload
6 inches
S&S of hyponatremia
lethargy
headache
confusion
apprehension
seizures
coma
hypervolemic hypernatremia
sodium increases more while body water increases not as much
hypovolemic hypernatremia and causes
body water decreases faster than sodium
adrenal insufficiency
V/D
suctioning
pseudohyperkalemia
lab error from:
traumatic venipuncture
hemolysis, thrombocytosis, leukocytosis
clenching of fist during phlebotomy
drugs that cause hyperkalemia
digoxin
K+ sparing diuretics
NSAIDS
ACE
BB
abx
heparins
penicillin G
IC shift hyperkalemia
K+ release due to cell lysis
K+ release with intact cell membrane
foods to avoid in chronic renal failure
dried fruits
seaweed
nuts, molasses
avocadoes
lima beans
spinach, potatoes, tomatoes, broccoli, carrots
kiwis, mangoes, oranges, bananas, cantalopue
Ca treatment given with what
Mg
2 electrolyte imbalances caused by low Mg
hypocalcemia bc mg needed for PTH
hypokalemia bc this induces K+ renal wasting
resp alkalosis S&S
Seizures
Hyperventilation
Tachycardia
Tachypnea
Decreased or normal BP
Hypokalemia
Numbness or tingling in extremities
Lethargy and confusion
Lightheadedness
Nausea, vomiting
Hypocalcemia
what to check in metabolic acidosis
potassium levels
Normal blood counts
normal PLT count is 144k
WBC: 4,500-11,000
resp alkalosis risk factors
Hyperventilation (most common cause)
Can cause hypocalcemia
anxiety
salicylates
disease states
mechanical over-ventilation
hypermetabolic states
acute hypoxia
pulmonary disease
severe anemia
pulmonary embolus
hypotension
syncope
hyperactive deep tendon reflexes
metabolic acidosis S&S
hyporeflexia
disoriented, weak, coma
N/V/D
dehydration
facial flushing (seen w kidney failure)
peripheral edema
weak pulse
hypotension
hyperventilation
